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4 Centre for Reviews and Dissemination, University of York, 2008 Published by CRD, University of York January 2009 ISBN This publication presents independent guidance produced by the Centre for Reviews and Dissemination (CRD). The views expressed in this publication are those of CRD and not necessarily those of the NHS, the NIHR or the Department of Health. All rights reserved. Reproduction of this book by photocopying or electronic means for non-commercial purposes is permitted. Otherwise, no part of this book may be reproduced, adapted, stored in a retrieval system or transmitted by any means, electronic, mechanical, photocopying, or otherwise without the prior written permission of CRD. Cover design by yo-yo.uk.com Prepared and printed by: York Publishing Services Ltd 64 Hallfield Road Layerthorpe York YO31 7ZQ Tel: Website:

7 PREFACE This third edition of the Centre for Reviews and Dissemination (CRD) guidance for undertaking systematic reviews builds on previous editions published in 1996 and Our guidance continues to be recommended as a source of good practice by agencies such as the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme, and the National Institute for Health and Clinical Excellence (NICE), and has been used widely both nationally and internationally. Our aim is to promote high standards in commissioning and conduct, by providing practical guidance for undertaking systematic reviews evaluating the effects of health interventions. WHY SYSTEMATIC REVIEWS ARE NEEDED Health care decisions for individual patients and for public policy should be informed by the best available research evidence. Practitioners and decision-makers are encouraged to make use of the latest research and information about best practice, and to ensure that decisions are demonstrably rooted in this knowledge. 1, 2 However, this can be difficult given the large amounts of information generated by individual studies which may be biased, methodologically flawed, time and context dependent, and can be misinterpreted and misrepresented. 3 Furthermore, individual studies can reach conflicting conclusions. This disparity may be because of biases or differences in the way the studies were designed or conducted, or simply due to the play of chance. In such situations, it is not always clear which results are the most reliable, or which should be used as the basis for practice and policy decisions. 4 Systematic reviews aim to identify, evaluate and summarise the findings of all relevant individual studies, thereby making the available evidence more accessible to decisionmakers. When appropriate, combining the results of several studies gives a more reliable and precise estimate of an intervention s effectiveness than one study alone. 5-8 Systematic reviews adhere to a strict scientific design based on explicit, pre-specified and reproducible methods. Because of this, when carried out well, they provide reliable estimates about the effects of interventions so that conclusions are defensible. As well as setting out what we know about a particular intervention, systematic reviews can also demonstrate where knowledge is lacking. 4, 9 This can then be used to guide future research. 10 WHAT IS COVERED IN THE GUIDANCE The methods and steps necessary to conduct a systematic review are presented in a core chapter (Chapter 1). Additional issues specific to reviews in more specialised topic areas, such as clinical tests (diagnostic, screening and prognostic), and public health are addressed in separate, complementary chapters (Chapters 2-3). We also consider questions relating to harm (Chapter 4) costs (Chapter 5) and how and why interventions work (Chapter 6). v

8 Systematic Reviews This guide focuses on the methods relating to use of aggregate study level data. Although discussed briefly in relevant sections, individual patient data (IPD) metaanalysis, which is a specific method of systematic review, is not described in detail. The basic principles are outlined in Appendix 1 and more detailed guidance can be found in the Cochrane Handbook 11 and specialist texts. 12, 13 Similarly, other forms of evidence synthesis including prospective meta-analysis, reviews of reviews, and scoping reviews are beyond the scope of this guidance but are described briefly in Appendix 1. WHO SHOULD USE THIS GUIDE The guidance has been written for those with an understanding of health research but who are new to systematic reviews; those with some experience but who want to learn more; and for commissioners. We hope that experienced systematic reviewers will also find this guidance of value; for example when planning a review in an area that is unfamiliar or with an expanded scope. This guidance might also be useful to those who need to evaluate the quality of systematic reviews, including, for example, anyone with responsibility for implementing systematic review findings. Given the purpose of the guidance, the audience it is designed for, and the aim to remain concise, it has been necessary to strike a balance between the wide scope covered and the level of detail and discussion included. In addition to providing references to support statements and discussions, recommended reading of more specialist works such as the Cochrane Handbook, 14 Systematic Reviews in the Social Sciences, 4 and Systematic Reviews in Health Care 15 have been given throughout the text. HOW TO USE THIS GUIDE The core methods for carrying out any systematic review are given in Chapter 1 which can be read from start to finish as an introduction to the review process, followed step by step while undertaking a review, or specific sections can be referred to individually. In view of this, and the sometimes iterative nature of the review process, occasional repetition and cross referencing between sections has been necessary. Chapters 2-5 provide supplementary information relevant to conducting reviews in more specialised topic areas. To minimize repetition, they simply highlight the differences or additional considerations pertinent to their speciality and should be used in conjunction with the core principles set out in Chapter 1. Chapter 6 provides guidance on the identification, assessment and synthesis of qualitative studies to help explain, interpret and implement the findings from effectiveness reviews. This reflects the growing recognition of the contribution that qualitative research can make to reviews of effectiveness. vi

9 Preface For the purposes of space and readability: The term review is used throughout this guidance and should be taken as a short form for systematic review, except where it is explicitly stated that non-systematic reviews are being discussed. Review question is used in the singular even though frequently there may be more than one question or objective set. The same process applies to each and every question. A glossary of terms has been provided to ensure a clear understanding of the use of those terms in the context of this guidance and to facilitate ease of reference for the reader. REFERENCES 1. Bullock H, Mountford J, Stanley R. Better policy-making. London: Centre for Management and Policy Studies; Strategic Policy Making Team. Professional policy making for the twenty first century. London: Cabinet Office; Wilson P, Petticrew M, and on behalf of the Medical Research Council s Population Health Sciences Research Network knowledge transfer project team. Why promote the findings of single research studies? BMJ 2008;336: Petticrew M, Roberts H. Systematic reviews in the social sciences: a practical guide. Malden, MA: Blackwell Publishing; Oxman AD. Meta-statistics: help or hindrance? ACP J Club 1993;118:A L Abbe KA, Detsky AS, O Rourke K. Meta-analysis in clinical research. Ann Intern Med 1987;107: Thacker SB. Meta-analysis: a quantitative approach to research integration. JAMA 1988;259: Sacks HS, Berrier J, Reitman D, Acona-Berk VA, Chalmers TC. Meta-analysis of randomized controlled trials. N Engl J Med 1987;316: Petticrew M. Why certain systematic reviews reach uncertain conclusions. BMJ 2003;326: Brown P, Brunnhuber K, Chalkidou K, Chalmers I, Clarke C, Fenton M, et al. How to formulate research recommendations. BMJ 2006;333: Stewart LA, Tierney JF, Clarke M. Chapter 19: Reviews of individual patient data. In: Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions. Version (updated February 2008): The Cochrane Collaboration; Available from: vii

15 Core principles and methods for conducting a systematic review of health interventions 1.1 GETTING STARTED There are a number of reasons why a new review may be considered. Commissioned calls for evidence synthesis are usually on topics where a gap in knowledge has been identified, prioritised and a question posed. Alternatively the idea for a review may be investigator led, with a topic identified from an area of practice or research interest; such approaches may or may not be funded. Whatever the motivation for undertaking a review the preparation and conduct should be rigorous Is a review required? Before undertaking a systematic review it is necessary to check whether there are already existing or ongoing reviews, and whether a new review is justified. This process should begin by searching the Database of Abstracts of Reviews of Effects (DARE), 1 and the Cochrane Database of Systematic Reviews (CDSR). 2 DARE contains critical appraisals of systematic reviews of the effects of health interventions. CDSR contains the full text of regularly updated systematic reviews of the effects of health care interventions carried out by the Cochrane Collaboration. Other sites to consider searching include, the National Institute for Health and Clinical Excellence (NICE) and the NIHR Health Technology Assessment (NIHR HTA) programme websites. The Campbell Collaboration website 3 contains the Campbell Library of Systematic Reviews giving full details of completed and ongoing systematic reviews in education, crime and justice, and social welfare; and the Evidence for Policy and Practice Information (EPPI) Centre, 4 whose review fields include education, health promotion, social care and welfare, and public health, has a database of systematic and non systematic reviews of public health interventions (DoPHER). It may also be worth looking at sites such as the National Guidelines Clearinghouse (NGC) 5 or the Scottish Intercollegiate Guidelines Network (SIGN), 6 as many guidelines are based on systematic review evidence. Searching the previous year of MEDLINE or other appropriate bibliographic databases may be helpful in identifying recently published reviews. If an existing review is identified which addresses the question of interest, then the review should be assessed to determine whether it is of sufficient quality to guide policy and practice. In general, a good review should focus on a well-defined question and use appropriate methods. A comprehensive search should have been carried out, clear and appropriate criteria used to select or reject studies, and the process of assessing study quality, extracting and synthesising data should have been unbiased, reproducible and transparent. If these processes are not well-documented, confidence in results and inferences is weakened. The review should report the results of all included studies clearly, highlighting any similarities or differences between studies, and exploring the reasons for any variations. Critical appraisal can be undertaken with the aid of a checklist 7-10 such as the example outlined in Box 1.1. Such checklists focus on identifying flaws in reviews that might bias the results. 8 Quality assessment is important because the effectiveness of interventions may be masked or exaggerated by reviews that are not rigorously conducted. Structured abstracts included in the DARE database 1 provide worked examples of how a checklist can be used to appraise and summarise reviews. 3

16 Systematic Reviews If a high quality review is located, but was completed some time ago, then an update of the review may be justified. Current relevance will need to be assessed and is particularly important in fields where the research is rapidly evolving. Where appropriate, collaboration with the original research team may assist in the update process by providing access to the data they used. However, little research has been conducted on when and how to update systematic reviews and the feasibility and efficiency of the identified approaches is uncertain. 11 If a review is of adequate quality and still relevant, there may be no need to undertake another systematic review. Where a new systematic review or an update is required, the next step is to establish a review team and possibly an advisory group, to develop the review protocol. Box 1.1: Critically appraising review articles Was the review question clearly defined in terms of population, interventions, comparators, outcomes and study designs (PICOS)? Was the search strategy adequate and appropriate? Were there any restrictions on language, publication status or publication date? Were preventative steps taken to minimize bias and errors in the study selection process? Were appropriate criteria used to assess the quality of the primary studies, and were preventative steps taken to minimize bias and errors in the quality assessment process? Were preventative steps taken to minimize bias and errors in the data extraction process? Were adequate details presented for each of the primary studies? Were appropriate methods used for data synthesis? Were differences between studies assessed? Were the studies pooled, and if so was it appropriate and meaningful to do so? Do the authors conclusions accurately reflect the evidence that was reviewed? The review team The review team will manage and conduct the review and should have a range of skills. Ideally these should include expertise in systematic review methods, information retrieval, the relevant clinical/topic area, statistics, health economics and/or qualitative research methods where appropriate. It is good practice to have a minimum of two researchers involved so that measures to minimize bias and error can be implemented at all stages of the review. Any conflicts of interest should be explicitly noted early in the process, and steps taken to ensure that these do not impact on the review process. 4

17 Core principles and methods for conducting a systematic review of health interventions The advisory group In addition to the team who will undertake the review there may be a number of individuals or groups who are consulted at various stages, including for example health care professionals, patient representatives, service users and experts in research methods. Some funding bodies require the establishment of an advisory group who will comment on the protocol and final report and provide input to ensure that the review has practical relevance to likely end users. Even if this is not the case, and even where the review team is knowledgeable about the area, it is still valuable to have an advisory group whose members can be consulted at key stages. Engaging with stakeholders who are likely to be involved in implementing the recommendations of the review can help to ensure that the review is relevant to their needs. The particular form of user involvement will be determined by the purpose of the consultation. For example, when considering relevant outcomes for the review, users may suggest particular aspects of quality of life which it would be appropriate to assess. An example of a review which incorporated the views of users to considerable effect is one evaluating interventions to promote smoking cessation in pregnancy, which included outcomes more relevant to users as a result of their involvement. 12 However, consultation is time consuming, and needs to be taken into account in the project timetable. Where reviews have strict time constraints, wide consultation may not be possible. At an early stage, members of the advisory group should discuss the audiences for whom the review findings are likely to be relevant, helping to start the planning of a dissemination strategy from the beginning of the project. The review team may also wish to seek more informal advice from other clinical or methodological experts who are not members of the advisory group. Likewise, where an advisory group has not been established, the review team may still seek advice from relevant sources. Summary: Getting started Whatever the motivation for undertaking a review the preparation and conduct should be rigorous. A search of resources such as the DARE database should be undertaken to check for existing or ongoing reviews, to ensure a new review is justified. A review team should be established to manage and conduct the review. The membership should provide a range of skills, including expertise in systematic review methods, information retrieval, the relevant clinical/topic area, statistics, health economics and/or qualitative research methods where appropriate. Formation of an advisory group including, for example, health care professionals, patient representatives, services users and experts in research methods may be a requirement of some funding bodies. In any event, it may be valuable to have an advisory group, whose members can be consulted at key stages. The review team may wish to seek advice from a variety of clinical or methodological experts, whether or not an advisory group is convened. 5

18 Systematic Reviews 1.2 THE REVIEW PROTOCOL Introduction The review protocol sets out the methods to be used in the review. Decisions about the review question, inclusion criteria, search strategy, study selection, data extraction, quality assessment, data synthesis and plans for dissemination should be addressed. Specifying the methods in advance reduces the risk of introducing bias into the review. For example, clear inclusion criteria avoids selecting studies according to whether their results reflect a favoured conclusion. If modifications to the protocol are required, these should be clearly documented and justified. Modifications may arise from a clearer understanding of the review question, and should not be made because of an awareness of the results of individual studies. Further information is given in Section How to deal with protocol amendments during the review. Protocol development is often an iterative process that requires communication within the review team and advisory group and sometimes with the funder Key areas to cover in a review protocol This section covers the development of the protocol and the information it should contain. The formulation of the review objectives from the review question and the setting of inclusion criteria are covered in detail here as these must be agreed before starting a review. The search strategy, study selection, data extraction, quality assessment, synthesis and dissemination are also mentioned briefly as they are essential parts of the review protocol. However, to avoid repetition, full details of the issues related to both protocol requirements and carrying out the review are provided in Section 1.3 Undertaking the review Background The background section should communicate the key contextual factors and conceptual issues relevant to the review question. It should explain why the review is required and provide the rationale underpinning the inclusion criteria and the focus of the review question, for example justifying the choice of interventions to be considered in the review Review question and inclusion criteria Systematic reviews should set clear questions, the answers to which will provide meaningful information that can be used to guide decision-making. These should be stated clearly and precisely in the protocol. Questions may be extremely specific or very broad, although if broad, it may be more appropriate to break this down into a series of related more specific questions. For example a review to assess the evidence on the positive and negative effects of population-wide drinking water fluoridation strategies to prevent caries, 13 was undertaken by addressing five objectives: 6

19 Core principles and methods for conducting a systematic review of health interventions Objective 1: What are the effects of fluoridation of drinking water supplies on the incidence of caries? Objective 2: If water fluoridation is shown to have beneficial effects, what is the effect over and above that offered by the use of alternative interventions and strategies? Objective 3: Does water fluoridation result in a reduction of caries across social groups and between geographical locations, bringing equity? Objective 4: Does water fluoridation have negative effects? Objective 5: Are there differences in the effects of natural and artificial water fluoridation? Where there are several objectives it may be necessary to prioritise by importance and likelihood of being able to answer the question. It may even be necessary to restrict the scope of the question to a level that is manageable within set resources. For clarity, the singular term review question is used throughout the guidance. Box 1.2: Example review objective and PICOS elements for a review protocol Review objective The objective of this review is to assess the clinical effectiveness of treatments for childhood retinoblastoma. 14 Participants Studies of participants diagnosed with retinoblastoma at the age of 18 years or under. Studies of adults where childhood retinoblastoma was followed up into adulthood. Studies of mixed diagnoses if outcomes were reported separately for children with retinoblastoma. Interventions Any intervention or combination of interventions given for the treatment of retinoblastoma, including (but not restricted to) enucleation, external beam radiotherapy, chemotherapy, brachytherapy, cryotherapy, thermotherapy and photocoagulation. Outcomes Any clinical outcome, including (but not restricted to) survival, progression-free survival, tumour response, preservation of the eye, visual acuity, disease remission and adverse effects. Study design Randomised controlled trials (RCTs) and controlled trials. However, it is not anticipated that many studies of these designs will be available. Therefore, if information from controlled trials is not available, cohort studies are eligible for inclusion provided that data from a comparison group are reported. Case series and case reports are excluded from the review owing to the high potential for bias in these study designs. Case control studies (except where nested as part of a cohort study) and economic evaluations are also excluded. 7

20 Systematic Reviews The review question can be framed in terms of the population, intervention(s), comparator(s) and outcomes of the studies that will be included in the review. These elements of the review question, together with study design, will then be refined in order to determine the specific inclusion criteria that will be used when selecting studies for the review. Although both the acronyms PICO or PICOS are commonly used, here the term PICOS will be used throughout Population Interventions Comparators Outcomes Study design for consistency. In some situations, not all the elements will be relevant, for example not every review question will specify type of study design to be included. The use of PICOS in the context of reviews incorporating different study designs is discussed in the relevant chapters. The review question may be presented in general terms, for example, What is the best treatment option for retinoblastoma? More often the actual question is discussed by the review team and an objective, or series of objectives, framed by the population, the intervention and the outcome(s) of interest agreed. For example, The objective of this review is to assess the clinical effectiveness of treatments for childhood retinoblastoma. 14 The PICOS elements for this example are shown in Box 1.2. Population The included population should be relevant to the population to which the review findings will be applied, and explicit inclusion criteria should be defined in terms of the disease or condition of interest. Any specified restrictions should be clinically justifiable and relevant. Eligibility must usually be applied to the whole study and consideration of how to deal with studies that include a mixed population, some of whom are relevant to the review and some of whom are not, is required. If the inclusion criteria are broad, it may be informative to investigate effectiveness across subgroups of participants. However, in the absence of individual patient data (IPD), or very detailed reporting of data, broken down by participant characteristics, it is unlikely that inclusion can be restricted to particular types of participant or that detailed subgroup analyses will be possible. Where analysis of participant subgroups is planned, this should be specified in the protocol. Examples of factors that may be investigated include participants gender, age, disease severity, the presence of any co-morbidities, socio-economic status, ethnicity and geographical area. Interventions and comparators The nature of the interventions explored in the review may be framed in very broad terms like psychosocial interventions or may be more specific such as cognitive behavioural therapy. Factors usually specified include the precise nature of the intervention (e.g. the method of administration of a drug), the person delivering the intervention (e.g. a community psychiatric nurse versus a non-professional carer) or setting in which the intervention is delivered (e.g. inpatient or outpatient). Where comparative studies are to be included, the protocol should also specify which comparators are eligible. As with the interventions, comparators should be carefully defined, so that the scope of a term such as palliative care or usual care is clear. The protocol should also specify whether any co-interventions carried out at the same time affect eligibility for inclusion; this applies to both the intervention(s) and the comparator(s). 8

Systematic Reviews knowledge to support evidence-informed health and social care By removing uncertainties in science and research, systematic reviews ensure that only the most effective and best-value

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